UPDATE IN MANAGEMENT OF Done by : Dr.

Ozoof Alghashmari

CONJUNCTIVITIS Supervised by : Dr.Amna Altwirqi

OBJECTIVES:
1- Definition
2- Causes
3- Diagnosis
4- Treatment
5- When to refer
6- Reference
DEFINITION :
Conjunctivitis is inflammation of the mucous membrane that lines the surface of the
eyeball and inner eyelids.

" The conjunctiva is the mucous membrane that lines the inside surface of the lids and
covers the surface of the globe up to the limbus (the junction of the sclera and the
cornea).
CLASSIFICATION :
Conjunctivitis

Infectious Non-infectious

Bacterial Viral Allergic Non-allergic

VIRAL CONJUNCTIVITIS :
v Highly contagious.

v Adenovirus is most common cause .

v It constitutes 80% of all cases of acute conjunctivitis.

v Adenoviral conjunctivitis usually cause epidemic keratoconjunctivitis and follicular

conjunctivitis.
HISTORY :
v Watery or mucoserous discharge, patients may report morning crusting followed by
watery discharge

v Burning, grittiness, foreign body sensation and minimal to no itching

v Often unilateral, commonly spreads to other eye within 1—2 days

v History of acute concurrent viral illness or sick contact

RISK FACTORS:
Direct contact with:

1. Contaminated fingers
2. Medical instruments
3. Swimming pool water
4. Personal items from an infected person
EXAMINATION:
v Erythema of palpebral or bulbar conjunctive, lid edema, and chemosis
v The tarsal conjunctiva may have a follicular appearance
vPre- oracular lymphadenopathy
MANAGEMENT:
v Self-limited, supportive care with cold compresses, ocular antihistamines, and
artificial tears.

v Frequent hand washing, avoid sharing personal items like face towels

v Work and school restrictions

v Educate the patient that it’s usually worse the first 3—5 days and resolves after
2—3 weeks, may be longer if cornea is involved
TOPICAL ANTIHISTAMINE
 HERPES VIRUS CONJUNCTIVITIS:
v Herpes simplex virus (HSV) comprises 1.3-4.8% of all cases of acute conjunctivitis
and conjunctivitis caused by the virus is usually unilateral.
v Primary HSV-l infection in humans occurs as a non-specific upper respiratory tract
infection.
v HSV spreads from infected skin and mucosal epithelium via sensory nerve axons to
establish latent infection in associated sensory CN V and its ganglia. Latent infection
of the trigeminal ganglion occurs in the absence of recognized primary infection, and
reactivation of the virus may follow any of the three branches.
HISTORY:
v When primary ocular HSV infection occurs, the patient typically manifests
unilateral, thin, and watery discharge and sometimes accompanying vesicular eyelid
lesions.

v In a small percentage of patients, there is a history of external ocular HSV infection

that may lead to the diagnosis.
EXAMINATION:
v Eyelids often are edematous and ecchymotic. Watery discharge and preauricular
lymphadenopathy may be present. Usually unilateral.

v Cutaneous or eyelid margin vesicles, or ulcers on the bulbar conjunctiva

v The cornea often demonstrates a punctate epitheliopathy. In severe cases, there can
be a corneal epithelial defect (Dendritic epithelial keratitis). It typically begins in one
eye and progresses to the fellow eye over a few days.
Dendritic epithelial eyelid margin
keratitis vesicles
MANAGEMENT:
v Topical and oral antivirals are recommended to shorten the course of the disease.

Acyclovir:
v200, 400, 800 mg PO 5x/day for 10 days.
v5% dermatologic ointment, 6x/day for 7 days.

Ganciclovir:
v0.15% topical ophthalmic gel, 5x/day until epithelium heals; then 3x/day for 7 days
vTopical corticosteroids should be avoided because they potentiate the virus and may cause harm.
ALLERGIC CONJUNCTIVITIS:
v Caused by airborne allergen contacting the eye that trigger a classic (IgE)
mediated hypersensitivity response to that allergen.

v Often associated with atopic disease: allergic rhinitis, eczema, and asthma.

v Bilateral Itching and tearing.

HISTORY:
v Bilateral redness , watery discharge , itching ( the main symptom distinguishing it
from viral )

v History of atopy , seasonal allergy , specific allergy (eg. to cats)

v other allergic symptoms (eg. Nasal congestion , sneezing , wheezing ) may be

present.
EXAMINATION:
v Clinical findings are the same as those seen in viral conjunctivitis

v Both cause diffuse injection with bumpy or follicular appearance to the tarsal
conjunctiva

v Profuse watery or mucoserous , stringy discharge.

v Chemosis ( conjunctival edema ) in some cases.

MANAGEMENT :
v Avoid exposure to allergens and rubbing eyes
v Treat with artificial tears
v Over the counter topical antihistamine ± mast cell stabilizers
v Oral antihistamine
v Cold compresses
 Other Ex :

Topical Mast cell stabilizer

Topical Antihistamine
 v Mast cell stabilizer offer a preventive action and are most effective if used before the
onset of symptoms where possible (e.g. at the beginning of the pollen season as their
onset of action is relatively slow (5–7 days) and stinging upon instillation can occur
particularly in the presence of active inflammation, patients should be warned that their
eyes may initially feel worse.

In sever or resistant cases

v Surface-acting steroids:
(need referral to
v Fluorometholone ophthalmology)
v Rimexolone
v Topical Cyclosporine
BACTERIAL CONJUNCTIVITIS :
v Can be contracted directly from infected individuals, by an abnormal proliferation
of the native conjunctival flora, or from the spread of infection from the organisms
colonizing the patient's nasal and sinus mucosa.

v The most common pathogens for bacterial conjunctivitis :

Ø In adults are Staphylococcal species, followed by Streptococcus
pneumoniae and Haemophilus influenzae
Ø In children, the disease is often caused by H. influenzae , S. pneumoniae ,
and Moraxella catarrhalis.
vThe course of the disease usually lasts 7-10 days.
v Hyperacute bacterial conjunctivitis is often caused by Neisseria gonorrhoeae.

v When the infection does not respond to standard antibiotic therapy in sexually
active patients, Chlamydia trachomatis should be suspected.
RISK FACTORS:
v Contact with contaminated fingers, fomites or oculo-genital contact with someone
infected
v Young, sexually active adults below the age of 25 years, have a high risk,
especially if they do not use condoms on sexual encounters.
v Compromised tear production or drainage
v Disruption of the natural epithelial barrier of eye
vTrauma
v Immunosuppressed status
HISTORY:
v Patients complain of redness, grittiness, and purulent sticky discharge (eyes stuck
shut) in the morning.

v Conjunctivitis with hyperacute (<24 hours) onset of severe severity and very rapid
progression. Symptoms include massive exudation, severe chemosis, eyelid edema,
marked conjunctival hyperemia (Neisseria gonorrhoeae)
EXAMINATION:
v Red eye, purulent or mucopurulent discharge,
and chemosis.

v Bilateral mattering of the eyelids and adherence of the eyelids and lack of itching
are strong positive predictors of bacterial conjunctivitis

v Conjunctival papillae
MANAGEMENT:
Avoid spreading:

v Frequent hand washing

v Avoid sharing personal care objects such towels, cosmetics, etc
v Avoid contact with eyes
v Avoid shaking hands
v Strict instrument disinfection
MANAGEMENT:
v Most cases are self-limited within 1-2 weeks of presentation, but in cases caused by highly
virulent bacteria (e.g. S. pneumoniae, N. gonorrhoeae, and H. influenzae) antibiotic eyedrops
might be beneficial in reducing the duration of the conjunctivitis.

v There are no significant differences among the various broad-spectrum antibiotic eyedrops
in achieving a clinical cure. Factors that influence antibiotic choice are local availability,
patient allergies, resistance patterns, and cost.
TOPICAL ANTIBIOTIC

ü Usually self-limiting without antibiotics but

can improve remission rate
ü Contact lens users: Consider
fluoroquinolone due to risk of
Pseudomonas
ü Follow up after 2—3 days initially then
every 5—7 days until it resolves
ü Hyperacute bacterial conjunctivitis needs
immediate ophthalmological referral for
antibiotics
CHLAMYDIA TRACHOMATIS CONJUNCTIVITIS :
v Sexually transmitted infection (STI)
caused by certain types of C.
trachomatis.
v Concurrent asymptomatic urogenital
infection is typically present.
v Mostly unilateral, follicular
conjunctivitis of weeks to months duration
that has not responded to topical
antibiotic therapy.
MANAGEMENT:
• Concurrent chlamydial infection in adults should be managed with one of the
following:

ü Azithromycin 1000 mg single dose

ü Doxycycline 100 mg BID for 7 days
ü Tetracycline 250 mg QID for 7 days
ü Erythromycin 500 mg QID for 7 days
REASONS FOR URGENT OPHTHALMOLOGIC
REFERRAL:
v Reduction of visual acuity
v Ciliary flush – A pattern of injection in which the redness is most pronounced in a ring at the limbus,
This is concerning for infectious keratitis, iritis, and angle-closure glaucoma.
v Photophobia
v Severe foreign body sensation that prevents the patient from keeping the eye open
v Corneal opacity
v Fixed pupil
v Severe headache with nausea
v Suspicion for hyperacute bacterial conjunctivitis
REFERENCES: